elsevier items and derived items © 2007, 2002 by saunders, an imprint of elsevier inc. diabetes...

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc.Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc.

Diabetes

Irene Owens, MSN, ARNP

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc.

What Is Diabetes Mellitus?

• The inability of the body to produce or respond properly to the hormone insulin

• Results in a malfunction of carbohydrate, protein, and fat metabolism

• A chronic disease that requires lifelong behavioral changes

Slide 2


Types of Diabetes

Type 1 diabetes • Called insulin-dependent

diabetes mellitus or juvenile-onset diabetes

• Usually strikes children and young adults, although disease onset can occur at any age

• May account for 5% to 10% of all diagnosed cases of diabetes

Type 2 diabetes • Called non-insulin-dependent

diabetes mellitus or adult-onset diabetes

• Associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity

• Increasingly being diagnosed in children and adolescents

Slide 3


Diagnosis

• Fasting plasma glucose concentration of 126 mg/dL or greater

• 2-hour plasma glucose is 200 mg/dL or greater during an oral glucose tolerance test

Slide 4


Type 1 vs Type 2 Diabetes Mellitus

Type 1• Insulin deficiency• Abrupt onset• Ketosis prone• Generally not obese• Insulin dependent• Not responsive to oral agents• Onset usually 18 years or

younger

Type 2• Insulin resistance• Insidious onset• Not prone to ketosis• Usually obese• Non–insulin dependent• Responsive to oral

hypoglycemic medications• Onset usually in adults but seen

in obese adolescents

Slide 5


Type 1 Diabetes

Clinical manifestations• Polyphagia, polydipsia, and polyuria (“3 P’s”)• Unexplained weight loss• Blurred vision• Lack of energy• Diminished reflexes• Irritability• Nausea and vomiting• Fruity odor of breath• Kussmaul respirations

Slide 6


Type 1 Diabetes

• Incidence: 15 per 100,000 people in North America• Peak ages of onset: between 10 and 12 years of age in girls

and 12 to 14 years of age in boys • Risk increases if the child or adolescent has a first-degree

relative or identical twin with disease• Type 1 diabetes may show a familial tendency• Theories for disease development include genetic

components, environmental influences such as viruses, and an autoimmune response that causes the destruction of insulin-secreting cells of the pancreas in the islets of Langerhans

Slide 8


Type 1 DiabetesPathophysiology• 90% of the insulin-secreting cells (Beta) of the pancreas

are progressively destroyed• Absence of insulin available for metabolism causes fats

and proteins to be burned• Characterized by chronic hyperglycemia• Ketones are produced as a byproduct of fat metabolism • Ketones cannot be used by the cells in the absence of

insulin• Ketones accumulate in the blood, causing metabolic

acidosis and ketonuria

Slide 9


Insulin Therapy

Name of Insulin Onset of Action

Peak Effect after Injection

Humalog/Novolog (very short acting) 5-15 min 30-60 min

Regular/short acting 30 min 2-3 hr

NPH/intermediate acting 1-2.5 hr 6-9 hr

Lente/intermediate acting 2-4 hr 8-12 hr

Ultra Lente/long acting

Lantus (glargine)/long acting

4-6 hr

None

8-15 hr

24 hr

Combinations: 70/30, 50/50, 75/25 30 min 7-12 hr

Slide 10


Complications of Insulin Therapy

• Lipoatrophy• Lipohypertrophy• Dawn phenomenon• Somogyi’s phenomenon


Acute Complications of Diabetes

• Diabetic ketoacidosis (DKA)• Hyperglycemic-hyperosmolar state (HHS)- was

called Hyperglycemic-hyperosmolar-nonketotic syndrome (HHNS) in the past

• Hypoglycemia from too much insulin or too little glucose

Slide 12


Insulin Therapy

• Divided as two thirds before breakfast and one third before dinner

• Two thirds as intermediate, one third as short or rapid

• Twice-daily regimen most common

Slide 13


Insulin Therapy

• Rotation of sites• Mix insulin from clear to cloudy• Inject in subcutaneous tissue • Do not premix any insulin unless advised• Timing of injections in relation to meals• Insulin can be stored at room temperature• Only regular insulin may be administered

intravenously

Slide 14


Insulin Delivery Systems

• Current systems– Syringes– Insulin pens – Insulin pumps

Slide 15


Monitoring• Glucose testing is more accurate and is the

preferred method of monitoring glucose levels• Glycosylated hemoglobin (hemoglobin A1c)

level is usually measured every 3 months to evaluate long-term control

• The higher the hemoglobin A1c, the poorer the control has been over the last 3 months

Slide 16


Benefits of Regular Physical Activity

• Helps the body use glucose more effectively• Weight loss and maintenance• Increases HDL and lowers LDL cholesterol• Lowers blood glucose levels• Muscular strength • Cardiorespiratory (aerobic) fitness• Increases bone mass

(through weight-bearing activities)• Relieves anxiety and stress • Increases self-esteem

Slide 17


Complications of Diabetes: Hypoglycemia

Blood sugar of usually less than 70 mg/dLClinical manifestations• Shakiness, dizziness • Sweating • Hunger • Headache • Irritability • Pale skin color • Sudden moodiness or behavior changes, such as crying for

no apparent reason • Blurred vision • Increased heart rate • Weakness and fatigue

Slide 19


Complications of Diabetes: Hypoglycemia

Causes• Too little food • Too much insulin • Extra or vigorous exercise Treatment• Severe symptoms may require administration of

intramuscular glucagon• Fruit juice, carbonated soda, several hard candies• Follow with some protein and a complex carbohydrate• Test and monitor blood sugar once symptoms subside

Slide 20


Complications of Diabetes: Hyperglycemia

Blood glucose greater than 180 mg/dL and stays there for several readingsClinical manifestations• Extreme thirst• Frequent urination• Blurred vision• Drowsiness• Nausea• Hunger

Slide 22


Complications of Diabetes: Hyperglycemia

Causes• Not enough insulin• Larger food intake than usual• Less exercise than usual• Illness such as cold or flu• Stresses from family, school, or personal

situationsTreatment• Push sugar-free liquids• Insulin• Activity

Slide 23


Illness Management• Continue insulin treatment Patients with type 1 diabetes need insulin to live. Illness

often increases the amount of insulin the body needs. Insulin should never be withheld.

• Stay close to the meal planIf a patient has an upset stomach and cannot eat, give clear liquids that contain carbohydrates (sports drinks, juices, gelatin, broth, frozen fruit bars).

• Give plenty of liquidsEncourage the patient to drink as much water and other noncaffeinated beverages as possible.

Slide 24


Illness Management

Choose medications wisely• Many over-the-counter medications contain

sugar and/or alcohol.• Glucose in medications can rapidly add up;

patients should look for a glucose-free version of the medication. If unavailable, carbohydrates must be accounted for in the meal plan.

• Alcohol-free medicines are best.• Many decongestants can raise blood glucose

levels.Slide 25


Food for Sick Days

Fluids• 1 double-stick popsicle • 1 cup electrolyte sports

drink • 1 cup soup • 1/2 cup fruit juice • 1/2 cup regular soft drink

(not diet)

Solids• Crackers • Vanilla wafers • Graham crackers • 1 slice dry toast

(not light bread) • Mashed potatoes • Regular gelatin dessert

• Patients may not want to eat when sick • They must eat to keep the body from burning fats for fuel and

to speed healing. • Food ideas for sick days for patients with diabetes include:

Slide 26


Long-Term Complications of Diabetes

• Microvascular problems– Neuropathy– Retinopathy– Nephropathy

• Macrovascular problems– Peripheral vascular disease– Atherosclerosis

Slide 27


Developmental Issues

Infants• Very rapid growth • Continuing brain development • Trusting relationships with the parents • Erratic eating habits

(food can become a power struggle) • Erratic sleep patterns • Treatment schedule is difficult to keep because

of feeding and sleeping patterns

Slide 28



Toddlers • Can participate in some self-care • Look for parental approval while they test their

limits • Show decreased appetite and picky eating

habits (easily distracted from eating) • Begin to show more regular sleep patterns• Difficult to distinguish a low blood sugar

reaction from a normal temper tantrum

Slide 29



Preschool• Peer issues begin to emerge • Can understand rules • Can perform more self-care, including blood tests

under parental supervision • Eating behavior is less erratic • Very energetic, so hypoglycemia can be a problem • Regular sleep patterns • May be more challenging to provide snacks and

meals that match what siblings and friends eat

Slide 30



School age• Fear of being different from other children • Can perform most self-care, including blood tests

and insulin injections • Eager to learn • Beginning to understand consequences of their

actions • Tests independent decision making • Most time spent away from home

Slide 31



Early adolescence• Erratic growth, which affects insulin requirements • Glucose control may be erratic in spite of everyone’s

best efforts • Concerned about body image • Greatly influenced by friends • May challenge authority • Development of self-esteem • Beginning to understand abstract concepts

Slide 32



Adolescence• Puberty is well underway • Concerned with physical appearance • Clearer sense of self (can set goals) • Increased autonomy • Risk-taking behaviors, including not taking insulin and

not performing blood sugar tests • Many social activities are unpredictable• Counseling regarding contraception, alcohol,

and smoking

Slide 33


Proper Foot Care

• Foot injury is the most common complication of diabetes leading to hospitalization

• Prevention of high-risk conditions• Peripheral sensation management• Footwear• Foot care


Chronic Pain

• Neuropathic pain results from damage to the nervous system anywhere along the nerve

• Pharmacologic agents• Nonpharmacologic interventions


Ineffective Tissue Perfusion: Renal

• Interventions include:– Control of blood glucose levels– Yearly evaluation of kidney function– Control of blood pressure levels– Prompt treatment of UTIs– Avoidance of nephrotoxic drugs– Diet therapy– Fluid and electrolyte management


Risk for Injury Related to Disturbed Sensory Perception: Visual

• Interventions include:– Blood glucose control– Environmental management:

• Incandescent lamp• Coding objects• Syringes with magnifiers• Use of adaptive devices


Potential for Hypoglycemia• Blood glucose level <70 mg/dL• Diet therapy—carbohydrate replacement• Drug therapy—glucagon, 50% dextrose,

diazoxide, octreotide• Prevention strategies for:

– Insulin excess– Deficient food intake– Exercise– Alcohol


Resources for Parents and Children

• American Diabetes Association www.diabetes.org/home.jsp

• Children with Diabeteswww.childrenwithdiabetes.com/index_cwd.htm

• KidsHealthkidshealth.org

• The Lawson Wilkins Pediatric Endocrine Society www.lwpes.org

• The Magic Foundationwww.magicfoundation.org

• The US National Library of Medicine National Institutes of Healthwww.nlm.nih.gov/medlineplus/encyclopedia.html

Slide 39

http://www.childrenwithdiabetes.com/index_cwd.htm

elsevier items and derived items © 2007, 2002 by saunders, an imprint of elsevier inc. diabetes...

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